Provider Demographics
NPI:1871997098
Name:DITTRICH, KRISTINA (PHARMD)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:DITTRICH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 N JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:56087-1714
Mailing Address - Country:US
Mailing Address - Phone:507-723-7782
Mailing Address - Fax:
Practice Address - Street 1:625 N JACKSON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MN
Practice Address - Zip Code:56087-1714
Practice Address - Country:US
Practice Address - Phone:507-723-7782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121344183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist